You don't have to face this alone.

A Woman Like You Foundation of Kentuckiana helps women battling cancer in the Kentuckiana area with rent, mortgage, car payments, and utilities.

This application is for single women residing in the Kentuckiana area who are battling cancer and lack sufficient health insurance and/or financial resources.

Takes about 10–15 minutes. Nothing to print — you can even sign with your finger at the end.

About you

Let's start with your basic information.

Your information

Full name *

Age *

Date of birth *

Social Security Number * Used only to verify your application. Kept confidential.

Mailing address *

City *

State *

ZIP *

Phone number *

My physical address is different from my mailing address

Physical address

City

State

ZIP

Phone at this address

Your illness

Diagnosis *

Date diagnosed *

General prognosis

Medical contacts

So we can verify your condition.

Physician name *

Physician address

Physician phone *

Social worker name *

Social worker address

Social worker phone *

Insurance & finances

This helps us understand your household's need. It's shared only with our Board and kept confidential.

Insurance

Health insurance, Medicare, or Medicaid

Household & income

How many people live in your household? * Include yourself.

Who else lives in your household? List each person besides yourself — for example, a child, parent, or other relative.

	You ($/yr)	Other Household Members ($/yr)
Wages
Social Security
Disability
Other

Residence

Do you own or rent your home? *

Own Rent

Monthly mortgage or rent payment ($)

Other assistance & your request

Assistance you've applied for

Health insurance (list insurer)

Medicare / Medicaid

Fuel assistance, Social Security Disability, Welfare Office, or VA aid

Other

Anything else to consider

What you need help with

Types of financial assistance or resources you require * Note: we're not able to cover medical expenses directly.

A couple more contacts

Only fill these in if they apply to you — otherwise, skip ahead.

Someone else is submitting this application for me

Submitted on your behalf by

Name

Address

City, State, ZIP

Phone

Relation to applicant

Who should we contact about fund distribution?

Leave blank if it's you.

Name

Address

City, State, ZIP

Phone

Relation to applicant

Upload your bills

Take a photo or choose images of the bills you need help with — rent, mortgage, car payment, or utilities. You can add more than one.

📷

Tap to add photos Take a new photo or choose from your photos

Please upload the full bill — the image must clearly show your name, address, and account number.

Review & sign

Two quick agreements, then sign with your finger below.

General release

I have read and agree to the General Release above.

Authorization to release medical records

I authorize the release of my medical records as described above.

Your signature

Type your full legal name *

Sign below with your finger or mouse *

Signature required

Witness name (optional) If someone is with you, they may add their name here. If not, that's okay — leave it blank.

Almost done

Please look this over, then send it to us.

Something went wrong sending your application. Please check your connection and try again, or visit awomanlikeyou.org to print and mail a paper application.

✓

Application sent

Thank you for trusting us with your story. Our team will review your application and reach out soon. If you have questions in the meantime, call us at (502) 802-3500 or (502) 608-7761.